Apparatus, system, and method for applying and adjusting a tensioning element to a hollow body organ

ABSTRACT

An adjustable support pad for adjustably holding a tensioning line used to apply tension to a body organ. The adjustable support pad can include a locking mechanism for preventing slidable movement of the tensioning element in one or both directions. The locking mechanism may include spring-loaded locks, rotatable cam-like structures, and/or rotatable spool structures. The adjustable support pad may be formed from rigid, semi-rigid, and/or flexible materials, and may be formed to conform to the outer surface of a body organ. The adjustable support pad can be configured to adjustably hold one or more separate tensioning lines, and to provide for independent adjustment of one or more tensioning lines or groups thereof.

RELATED APPLICATIONS

The is a continuation of U.S. patent application Ser. No. 11/371,599,filed Mar. 9, 2006, now U.S. Pat. No. 7,431,629 and entitled,“Apparatus, System, and Method for Applying and Adjusting a TensioningElement to a Hollow Body Organ,” the entire contents of which are herebyincorporated by reference herein.

FIELD OF THE INVENTION

The present invention relates generally to medical devices andparticularly to applying and adjusting tensioning elements to a bodyorgan.

BACKGROUND OF THE INVENTION

A variety of surgical procedures use tensioning elements to effectrepair of a body organ. For example, heart disease can be treated withsuch tensioning elements, which can be used to replace and/or assist thefunctioning of native structures.

One type of heart disease occurs when a ventricle becomes dilatated.Ventricular dilatation can reduce the heart's ability to pump blood, andcan lead to a significant increase in wall tension and/or stress. Suchwall tension and/or stress can lead to further dilatation, which canlead to heart failure. One method of treating this condition is to applytensioning elements to the heart wall which absorb some of the tensionproduced during heart operation, thereby reducing the tension in theheart wall. Determining the proper tension to apply via the tensioningelements can be difficult.

Heart valve disease is a widespread condition in which one or more ofthe valves of the heart fails to function properly. Diseased heartvalves may be categorized as either stenotic, wherein the valve does notopen sufficiently to allow adequate forward flow of blood through thevalve, and/or incompetent, wherein the valve does not close completely,causing excessive backward flow of blood through the valve when thevalve is closed. Valve disease can be severely debilitating and evenfatal if left untreated. Valve disease often involves damaged chordaetendineae, which are thread-like bands of fibrous connective tissue thatattach to the mitral or tricuspid valve at one end and to the papillarymuscles or the ventricular wall at the other end.

Various surgical techniques may be used to repair a diseased or damagedheart and/or heart valve. One method for treating defective valves isthrough repair or reconstruction. A repair technique that has been shownto be effective in treating incompetence is annuloplasty, in which theeffective size and/or shape of the valve annulus is modified by securinga repair segment, such as an annuloplasty ring, around the heart valveannulus. For example, the valve annulus may be contracted by attaching aprosthetic annuloplasty repair segment or ring to an interior wall ofthe heart around the valve annulus. The annuloplasty ring is designed tosupport the functional changes that occur during the cardiac cycle:maintaining coaptation and valve integrity to prevent reverse flow whilepermitting good hemodynamics during forward flow.

In many diseased valves, the chordae tendineae are either ruptured,otherwise damaged, or of an improper length. When chordae tendineae aretoo long, too short, or otherwise damaged, the corresponding tricuspidor mitral valve to which they are attached typically may fail to closeproperly. For example, chordae tendineae which are ruptured or are toolong allow a valve to prolapse, wherein one or more valve leaflets swingbackward past their proper closed position. This can lead toregurgitation, which is the unwanted backflow of blood from a ventricleto an atrium resulting from imperfections in the valve. When the valveallows such backward flow into an atrium, the corresponding ventriclemust pump progressively harder to circulate blood throughout the body,which in turn promotes congestive heart failure.

Repairing and/or replacing dysfunctional chordae tendineae has beenperformed for some time. The techniques for such repair are oftencomplicated due to the difficulties in accessing the surgical site, inidentifying the dysfunctional chordae tendineae, and in determining theproper length for the repaired and/or replacement chordae tendineae.Determining the proper length for replacement chordae tendineae can be acomplex procedure. Additionally, prior methods for replacing andadjusting the length of the chordae tendineae often involved making suchadjustments on an arrested heart, whereas the final test of theappropriateness of the adjusted length is typically performed while theheart is beating. According, what has been needed is a method ofadjusting replacement chordae lengths on a beating heart.

Accordingly, there has been a need for an improved apparatus, system,and method to apply and adjust tensioning members on and/or in a bodyorgan, including the repair and replacement of chordae tendineae onheart valves. The present invention satisfies one or more of theseneeds.

SUMMARY OF THE INVENTION

The present application is generally described with respect to its usein the repair of the mitral valve, which regulates blood flow from theleft atrium (LA) to the left ventricle (LV), and more specifically inthe replacement of chordae tendineae. However, the invention could alsobe applied to treatment of other body structures where application of anadjustable tensioning device is desired.

The invention includes an adjustable support pad system. The adjustablepad includes one or more adjustable securing elements, with eachsecuring element configured to retaining an end of a suture line orother tensioning element. The securing element is adjustable, so thatthe tension applied to the suture line can be adjusted. In oneembodiment the securing element is a rotatable spool-like structureabout which the suture line can be wound. The spool can be rotated inone or more directions to increase and/or reduce the tension in thesuture line. The securing element may include a locking mechanism, suchas a ratchet, segmented coil, clip, and/or cam.

The adjustable pad is configured to be attached to the outside of theorgan. In use, the adjustable pad is sutured or otherwise secured to theoutside of a body organ, with a tensioning element (such as a sutureline) passing from the adjustable pad, into the body organ, and to anopposing attachment point. A first end of the suture line is secured tothe tensioning element, and the second or opposing end of the sutureline is attached to the opposing attachment point. The opposingattachment point may be inside or outside the body organ.

In an embodiment, the adjustable pad can be sutured or otherwiseattached to the outside of the ventricle of a human heart. Theadjustable pad is configured to provide a supporting structure for oneend of the suture line or other tensioning element, thereby protect theorgan wall from damage that might occur if the suture line were attacheddirectly to the organ wall. The adjustable pad also provides the abilityto adjust the length of (and thereby the tension in) the suture line,without having to retie either end of the suture line. With theadjustable pad positioned on the outside of a human heart, a surgeoncould thus adjust the tension while the heart is beating, thuspermitting the surgeon to see the functioning of the heart (and hencethe effectiveness of the current tension setting in repairing heartfunction) in real time via echocardiography or other imaging techniqueswhile he or she is adjusting the tension in the suture line or othertensioning element.

The invention can be used for correction of mitral valve prolapse usingreplacement chordae, such as expanded neochordae suture (such aspolytetrafluroethylene (e-PTFE)). One or more replacement chordaesutures can be passed from an adjustable chordal pad, through the heartwall, and then tied in position on the desired leaflet. This part of theprocedure could also be reversed, with one or more replacement chordaesutures tied to the leaflet and passed through the heart wall to anadjustable chordal pad. The desired number and length of the replacementchordae depend on the needs of the particular patient, includingcharacteristics of the valve annulus, the valve leaflets, and theexisting chordae. This portion of the procedure can be performed on abeating or arrested heart.

With the replacement chordae in place, the surgeon can adjust thechordae length from the outside of the heart by adjusting the adjustablechordal pad. In one embodiment, the adjustable chordae pad includes anadjustable tensioning element in the form of a spool-like structure thatcan have an end of one or more replacement chordae wound therearound. Byrotating the spool-like structure in one direction or the other, thesurgeon or other user can shorten (tighten) or lengthen (loosen) thereplacement chordae. Depending on the particular application, one ormore adjustable chordal pads may be used on a patient's heart.Additionally, the adjustable support pad may have one or more separatespools, each of which may be separately adjustable from the otherspools. With separate replacement chordae wound upon separatelyadjustable spools on a single support pad, the support pad serves as aplatform for multiple replacement chordae.

The apparatus can be used in conjunction with other repair procedures onthe particular body organ or body structure involved. For example,replacing chordae tendineae can be combined with application of a heartvalve annuloplasty ring or other techniques that can reshape the heartvalve annulus to a desired shape, and/or prevent the heart valve annulusfrom further and undesired deformation. Moreover, the invention is notlimited to heart treatments. Other organs and body structures could alsobe treated. For example, the invention could be used to apply tension totreat a pelvic organ prolapse, to reinforce muscles, and/or to reshape abody structure.

The apparatus may include a flange and/or cannula that passes into thebody organ and which may provide a protective surface between the organwall and the tensioning element.

Various aspects of the invention can be used individually or incombination to repair a body organ. The invention is applicable tovarious ways of accessing the organ for repair, including an opensurgical approach or a minimally-invasive approach such as percutaneousor intercostal.

Other features and advantages of the present invention will becomeapparent from the following detailed description, taken in conjunctionwith the accompanying drawings which illustrate, by way of example, theprinciples of the invention.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 depicts a side view, in partial cross-section, of a device havinga tensioning element for application to a body organ according to anembodiment of the invention;

FIG. 2A depicts a side view, in partial cross-section, of a furtherembodiment of the invention;

FIG. 2B depicts a side view, in partial cross-section, of the device ofFIG. 2A with the cams in the open position;

FIG. 3A depicts a top view of an adjustable support pad according to afurther embodiment of the invention;

FIG. 3B depicts a side view, in partial cross section, of the apparatusof FIG. 3A;

FIG. 4A depicts a top view of an adjustable support pad according to afurther embodiment of the invention;

FIG. 4B depicts a side view of the apparatus of FIG. 4A;

FIG. 4C depicts a side view, in close up and partial cross-section, of aportion of the apparatus of FIGS. 4A and 4B;

FIG. 5 depicts a side view, in partial cross-section, of a furtherembodiment of the invention;

FIG. 6 depicts a side view, in partial cross-section, of a furtherembodiment of the invention;

FIG. 7 depicts a side view, in partial cross-section, of a furtherembodiment of the invention; and

FIG. 8 depicts a side view, in partial cross-section, of a system andmethod for applying replacement chordae to a human heart according to anembodiment of the invention;

FIG. 9 depicts a top view of a further embodiment of the invention;

FIGS. 10A and 10B depict side views, in partial cross-section, of afurther embodiment of the invention;

FIGS. 11A through 11C depict side views, in partial cross-section, offurther embodiments of the invention; and

FIGS. 12A and 12B depict perspective views of further embodiments of theinvention.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 depicts an adjustable support pad 10 according to an embodimentof the invention with a tensioning element in the form of a suture line12 under tension within an organ 14. The adjustable support pad 10 isplaced against the outside of the organ wall 16 and secured thereto viaordinary sutures 18 passing through suture holes 19 on the support pad10. The suture line 12 is secured to an attachment point 20 via a sutureknot 22. The suture line 12 passes from the attachment point 20 througha hole 24 in the adjustable pad 10 to a locking mechanism 26. With thesuture line 12 secured to the adjustable support pad 10, the suture line12 will have a tensioned portion 28 passing from the attachment point 20to the adjustable support pad 10, and a slack portion 30 which is pastthe adjustable support pad 10.

In the particular embodiment of FIG. 1, the adjustable pad 10 includes aprotective flange 32 which surrounds the pad hole 24 and is secured to agenerally tubular cannula 33 that passes through the organ wall 16. Theprotective flange 32 and cannula 33 may serve to protect the suture line12 and/or organ wall 16 from contact therebetween. Note that the flange32 and/or cannula 33 could be left off of the device, as in theembodiment of FIGS. 2A and 2B, so that the pad could be secured directlyto the organ wall without the pad itself puncturing or otherwise passingthrough the organ wall. The choice of whether to include the flange 32and/or cannula 33 depends on the particular application.

The locking mechanism can comprise one or more mechanisms that engagethe suture to prevent its movement in one or more directions. Forexample, in the embodiment of FIG. 1, the locking mechanism 26 comprisestwo movable engagement structures 34 that engage against the suture line12 to prevent it from moving with respect to the adjustable pad 10. Themovable engagement structures 34 engage against movable control buttons36 which a user can use to move the movable engagement structures 34into or out of engagement with the suture line 12. The device furtherincludes springs 38 which bias the movable engagement structures 34 intoengagement with the suture line 12, thereby biasing the lockingmechanism 26 to the locked position whereby movement of the suture lineis prevented in one or more directions. In the particular embodiment ofFIG. 1, movement of the suture line 12 is prevented in both directions(i.e., into the organ and out of the organ) when the movable engagementstructures 34 engage the suture line 12. Although the embodimentdepicted includes two movable engagement structures 34 in opposition toeach other, other numbers of movable engagement structures are withinthe scope of the invention. For example, a single such movableengagement structure could be used without a second opposing movableengagement structure. Such a single movable engagement structure couldbe combined with an opposing but non-movable engaging structure,depending on the particular application.

In some applications, fluid leakage out of the organ 14 through the padhole 24 may be of concern. In many cases the tightness of the pad hole24 about the suture line 12 can prevent such leakage. Natural bodilysealing processes, such as blood clotting and/or tissue ingrowth infront of or into the pad hole 24, can further prevent such leakage. Thepad hole 24 may include a sealant (not shown) against such leakage, suchas a biocompatible sealant positioned within the pad hole 24. Sizing thepad hole 24 so that the suture line 12 just fits therethrough, withoutsubstantial spacing between the suture line 12 and the walls of the padhole 24, will also help to prevent leakage. The walls of the pad hole 24could also be formed from flexible and/or padded material that placessome inward pressure against the suture line 12, thereby preventingfluid leakage. For example, a compressible material such as silicon oranother compressible polymer could form all or part of the walls of thepad hole 24, and would press inwardly against the suture line 12 if thepad hole 24 was sized correctly, e.g., sized with a diameter that willcompress against the suture line 12 to prevent leakage around the sutureline 12. The walls of the pad hole 24 might also be formed of, or linedwith, a biocompatible material that encourages tissue ingrowth, so thatthe tissue ingrowth acts to block leakage. Additionally, the lockingmechanism itself may help to prevent such leakage, in that the lockingmechanism, depending on the particular embodiment, may block all or asubstantial portion of the pad hole 24 that is not already taken up bythe suture line 12. In another embodiment, the flange or other materialin the support pad through which the suture is intended to pass could besolid (i.e., without a pre-formed pad hole therethrough) material, inwhich case the user could create a pad hole using a suturing needlethrough which the suture was threaded. The user would drive thesuture-threaded needle through the material, thus creating the pad holeand passing the needle and suture assembly through the newly-created padhole in the adjustable support pad. The suture would thus penetrate theflange or other material, creating a hole only large enough for thesuture material. If compressible material were involved, thecompressible material could engage against the small suture hole tofurther prevent leakage.

FIGS. 2A and 2B depict a further embodiment of the invention, wherein anadjustable support pad 10 includes a locking mechanism formed by twomovable engagement structures in the form of opposing cams 40. In FIG.2A the cams 40 are in the locked or engaging position whereinlongitudinal movement of the tensioning line 12 is prevented, but inFIG. 2B the cams 40 are rotated to their open or unlocked position. Thecams 40 may be biased by springs or other biasing devices [not shown]toward the closed position, but such bias may not be needed where thetension in the tensioned side 28 of the tensioning line 12, combinedwith contact with the cams 40 against the tensioning line 12 as ispasses through the cams 40, pulls the cams 40 to their closed position.

Note that the particular embodiment of FIGS. 2A and 2B does not includethe flange and cannula (elements 32 and 33 in FIG. 1). Accordingly,while the tensioning line 12 passes through the organ wall, theadjustable support pad 10 is secured directly to the outside of theorgan wall and does not puncture or otherwise pass through the organwall.

FIGS. 3A and 4B depict a further embodiment of the invention, with anadjustable support pad 10 having a lower “fixed” portion 42 and an upperrotatable portion 44. The support pad 10 includes several sets of sutureholes 46 through which suture can be passed to suture the support pad 10to the surface of an organ wall. The tensioning line 12 passes upthrough the pad hole 24, across the upper portion 44 and down throughthe suture slot 48, and is then secured to a suture tie point 50. Withthe tensioning element 12 thus secured to the support pad 10, the usercan rotate the upper portion 44, which will cause the tensioning element12 to be tightened as it is wrapped about a center spindle 52, which inthe embodiment of FIG. 3A is positioned on the upper portion 44 and willrotate therewith. Note, however, that the spindle could be fixed to thelower portion 42 of the adjustable support pad 10, in which case thespindle would not rotate as the tensioning line 12 was wound thereon. Inuse, the surgeon or other user secures the support pad 10 to the organwall (which can be accomplished via suture or other suitable attachmentmeans), leads the tensioning line 12 through the pad hole 24 into thesuture slot 48, ties off the tensioning line 12 to the tie point 50,adjusts the tension in the tensioning line 12 by rotating the upperrotatable portion 44 until the desired tension is achieved (which can beconfirmed by monitoring the organ characteristics during tensioning viaan imaging system such as echocardiography), and then secures the upperrotatable portion 44 in a fixed position so that it will not take in orlet out any additional tensioning line 12. The order of these stepscould be varied, depending on the particular application.

In the embodiment of FIGS. 3A and 3B, the spindle 50 includes an outercircumference 54 having notches 56. These notches 56 can be used tosecure the upper rotatable portion 44 in a fixed position. For example,once the desired tension in the tensioning line 12 was achieved, theuser could secure a suture line to a part of the fixed lower portion(such as one of the suture holes 46), then run that suture line acrossthe upper portion 44 and though one or more of the notches 56, and thenreturn the line to the fixed lower portion to be tied off. A suture linethus installed would prevent unwanted rotation of the upper portion 44.

The upper portion 44 can be configured to be easily snapped off of orotherwise removed from the lower portion 42, thus allowing the user toremove and/or replace the upper portion when necessary and/or convenientduring a particular procedure. For example, a user could initiallydisassemble the device prior to installation, and then pass thetensioning element out of the organ, thread the tensioning elementthrough the lower portion, secure the lower portion to the organ wall,thread the tensioning element through the upper portion, secure theupper portion to the lower portion, and then adjust the tension in thetensioning element. The user could also remove the upper portion afterthe lower portion was already secured to the organ wall.

FIGS. 4A and 4B depict a further embodiment of the invention where anadjustable support pad 10 includes a base portion 60 having a rotatableupper portion 62. In the particular embodiment depicted, the tensioningline would be passed through the pad hole 24, passes over the top of therotatable upper portion 62 through a tensioning line groove 63 and downthrough a slot 64, and is secured to the rotatable upper portion 62 atone or more suture tie-off holes 66. Note that these same tie-off holes66 can also be used to secure the adjustable pad 10 to the surface of abody organ via suture.

The rotatable upper portion 62 is rotated, causing the tensioning line12 to wrap around the spool 68 and thereby adjusting the tension in thetensioning line 12. In the embodiment of FIGS. 4A and 4B, there is aratchet-like structure 70 on the rotatable upper portion 62 that allowsthe rotatable upper portion 62 to be rotated in a first rotatabledirection 72, but prevents rotatable movement of the rotatable upperportion 62 in a second rotatable direction 74. The ratchet-likestructure 70, depicted in greater detail in FIG. 4C, includes an arm 76having an angled downward projection 78 at its end. The angled downwardprojection 78 has flat face 80 on one side and an angled face 82 on anopposing side. When the upper portion 62 is secured to the base portion60, the angled downward projection 78 lodges within gear-like recesses84 formed in the base portion 60 in a circular pattern of which at leasta portion lies underneath the angled downward projection 78 when theupper portion 62 is secured to the base portion 60. When the rotatableupper portion 62 is rotated in the first rotatable direction 72, theangled face 82 is presented to the gear-like recesses 84, which allowsthe rotatable upper portion 62 to rotate as the angled face 82 rises andfalls over the gear-like recesses 84. When the rotatable upper portion62 is rotated in the second rotatable direction 74, the flat face 80 ispresented to the gear-like recesses 84, which prevents rotation of therotatable upper portion 62 due to the engagement of the flat face 80against corresponding surfaces of the gear-like recesses 84. Note thatthe user can manually release the ratchet mechanism by lifting the arm76 until the angled downward projection 78 is clear of the gear-likerecesses 84, at which point the upper rotatable portion 62 may berotated in either direction 72, 74.

The embodiment depicted in FIG. 4A also includes locking suture holes 86a, 86 b on the rotatable upper portion 62, with a suture-receivinggroove 87 passing therebetween. A user can lock the rotatable upperportion 62 in place to prevent rotation in either rotatable direction72, 74 by passing a line of suture from one of the suture tie-off holes66 a, up through a first locking suture hole 86 a, across a suturegroove 87 in the top of the rotatable upper portion 62, back through asecond locking suture holes 86 b, and then to another of the suturetie-off holes 66 b. In the embodiment depicted, the suture groove 87passes over the tensioning line groove 63, so that a suture tightenedacross the suture groove 87 will engage the portion of the tensioningline passing through the tensioning line groove 63. With the suturetightened and tied off at either end to the suture tie-off holes 66 a,66 b, the suture will thus prevent rotation of the rotatable upperportion in either direction 72, 74, while also providing some resistanceagainst sliding of the tensioning line through the tensioning linegroove 63.

Depending on the particular application, one or more tensioning linescan be secured to a single adjustable support pad. For example, in thedevice depicted in FIG. 5, multiple tensioning lines 12 a, 12 b, 12 care slidably secured to a single adjustable support pad 10. The multipletensioning lines 12 a, 12 b, 12 c can be secured in place to preventsliding in one or more directions using locking mechanisms such as thosediscussed above.

In a further embodiment such as that depicted in FIG. 6, a singleadjustable support pad 10 includes multiple locking mechanisms 26 a, 26b, 26 c, each of which can secure one or more tensioning lines 12 a, 12b, 12 c. Such an embodiment can be particularly useful for applicationswhere there is a need for multiple tensioning lines that must beindividually secured and adjusted at a position where there is limitedroom for adjustable support pads. By separating the locking mechanismson a single pad, the tension of one or more individual tensioning linescan be easily adjusted without interfering with the tension in one ormore of the other tensioning lines secured to other locking mechanisms.

The adjustable support pad can be formed from various biocompatiblematerials, including metals, polymers, ceramics, and/or composites. Theadjustable support pad can also be configured to conform to the bodyorgan. For example, an adjustable support pad for use in replacingchordae tendineae can be configured to conform to the outer surface ofthe human heart, such as an outer surface at or adjacent the apex of theheart. Such an adjustable support pad could, for example, be initiallyformed having an organ-facing surface that generally matches thecorresponding outer surface of the heart to which the adjustable supportpad will be secured. The adjustable support pad can be formed as a rigidstructure, or can be formed as a generally flexible structure that canflex to modify its shape to better conform to the body organ of theparticular application.

The tensioning element can take various forms. It may be a commonsuture. For applications where the tension was desired to be temporary,or where body tissue was expected to grow and take over the role ofapplying the tension, the tensioning line and/or adjustable support padcould be formed from material that is absorbed over time. For otherapplications, however, the tensioning line and/or adjustable support padcan be formed from non-absorbable material. The tensioning element canalso contain bumps, ridges, or gears to facilitate one-directionaltensioning against a locking mechanism, and could allow for the releaseof such tensioning.

The tensioning line can include a shock absorbing component positionedbetween the adjustable support pad 10 and the tensioning line attachmentpoint 20 on the organ 14, such as the nitinol spring 88 depicted in thetensioning line 12 of FIG. 7, which may be particularly useful for anorgan that may flex and/or otherwise deform in shape to the point wheretension on a regular tensioning line might become excessive during organdeformation. In the case of a tensioning line being used as areplacement for chordae tendineae, the shock absorbing mechanism couldbe used to mimic the effect of the papillary muscle or muscles.

FIG. 8 depicts an adjustable support pad used to implant a tensioningline in the form of a replacement chordae 90 in a heart 92. A first end94 of the replacement chordae 90 has been attached to a heart valveleaflet 96. An adjustable support pad 10 has been secured to the heartouter surface 98, with the flange 32 and pad hole 24 penetrating theheart wall 100. In the embodiment depicted, the adjustable support pad10 is positioned adjacent the lower portion of the heart ventricle 102and adjacent the apex 104, which will approximate the attachmentposition of the native chordae being replace in this embodiment, whichwould have been attached to the papillary muscle which in turn isattached to the heart in the lower ventricular portion. The replacementchordae 90 has been passed through the heart wall 100 and into the padhole 24 of the adjustable support pad 10.

Note that the order of the steps discussed above could be varied. Forexample, the replacement chordae could be initially secured to theadjustable support pad 10, then passed through the heart wall 100 andsecured to the valve leaflet 96. Also, the steps could be performed on abeating heart, and/or on an arrested heart with the patient on bypass.

With the replacement chordae 90 and adjustable support pad 10 in place,the tension in the replacement chordae 90 can be adjusted to the desiredlevel. Adjusting the tension may preferably be performed on a beatingheart, but in some applications the heart may need to be arresteddepending on patient condition, etc. Adjusting the tension may beperformed concurrently with monitoring of the heart and valveperformance, which can be monitored by an imaging technique such asechocardiography. In the embodiment of FIG. 8, an imaging system 106provides real-time imaging of the heart and valve, with an imagingdevice 108 such as an ultrasound transducer providing a signal that isprocessed into images displayed on a display 110. The user can adjustthe tension while concurrently monitoring the performance of the heartvalve. Note that concurrently can include, but does not require,simultaneous monitoring and tensioning adjustment. For example, a usermay concurrently adjust the tension and monitor heart/valve performanceby making an initial adjustment to the tension, pausing to monitor theheart/valve performance on the imaging system, then make an additionaladjustment to the tension based on the monitored heart valveperformance, then pause again to monitor the performance, etc. After thedesired tension is achieved and the replacement chordae 90 is secured inthe adjustable support pad 10, any excess replacement chordae 90 (i.e.,the slack portion 30) can be cut off.

Various methods and devices can be used to adjust and/or maintain thetension. For example, the support pad may include a connecting and/orreceiving assembly/device for receiving an adjustment tool that canadjust the tension. As an example, a support pad having a rotatabletensioning adjustment mechanism, such as device discussed and depictedwith respect to FIGS. 4A, and 4B, could utilize a flat-head or Philipsscrewdriver-type connection, so that the user could use a simplescrewdriver to rotate the rotatable tensioning adjustment mechanism.Such a support pad 10 is depicted in FIG. 9, with a base portion 60 androtatable portion 62, wherein the rotatable portion 62 includes agenerally cross-shaped indentation 112 configured to receive aPhilips-head screwdriver tip. Other adjustment tools and connections arealso within the scope of the invention, such as an adjustment tool thatcan be easily connected to and disconnected from the support pad.

Another tool for adjusting tension may be an elongated adjustmentelement 114, such as a flexible adjustment wire or rod, that can remainpermanently or removably attached to the support pad 10 at a distal end113 end with the proximal end 115 extending outside of the patient'sbody 116 through the patient's skin 118, as depicted in FIG. 10A. Thesurgeon or other user can complete the installation of the support pad10 (which may include making initial tensioning adjustments to thetensioning element), and then close up the surgical openings in thepatient except for a small opening 120 (e.g., a port) out of which theelongated adjustment element 114 would extend. The user could thusadjust the tension during and after the procedure wherein the adjustablepad 10 was installed. For example, the patient may recover for a period,and then the surgeon or other user could re-examine the patient(possibly including imaging or other assessment of the patient's heartfunction) and perform tensioning adjustments externally in accordancewith the reexamination. The device could also include an apparatus andmethod for remotely disconnecting the elongated adjustment element 114from the support pad 10, so that once the surgeon or user is satisfiedwith the tensioning, the elongated adjustment element 114 could beremotely disconnected from the support pad 10 and removed from thepatient 116 without performing major surgery, as depicted in FIG. 10B.

Another device and method for adjusting the tension can include the useone or more small motors, such as an electric motor 122, that can beincluded in the support pad 10 itself, as in FIG. 11A. As depicted inFIG. 11A, the support pad 10 may also include one or more sensors 124 tomonitor tension, one or more controllers 126 (such as microprocessors)to process tension signals and control the motor 122 to adjust thetension, and or more batteries 128 to power the motor 122, controller126, and/or sensor 124.

In another embodiment, depicted in FIG. 11B, the electric motor 122 andbattery 128 are located some distance from the support pad 10, such asat a location on or near the surface of the patient's skin 118. In theembodiment depicted in FIG. 11B, an electric motor 122 is located underbut adjacent the patient's skin 118 and other external tissue, in afashion similar to the locating of modern pacemakers. The electric motor122 is connected to the support pad 10 via a elongated shaft 130, whichcan be flexible or rigid and, in the embodiment depicted in FIG. 11B,serves to translate motor rotation into rotation of the rotatableportion 62 of the particular support pad 10 depicted. In such anembodiment, the controller and/or sensor (not depicted), if present, canbe located with the support pad 10, with the battery 128 and/or motor122, or elsewhere.

Another embodiment is depicted in FIG. 11C, wherein the motor 122 itselfis located in the adjustable support pad 10, but the battery 128 topower the motor 122 is positioned remotely under the patient's skin 118and external tissue. The battery 128 provides electricity to the motor122 via one or more small wires 132. In such an embodiment, the motorcontrols and/or tension sensors (if present) could be located with thebattery 128, with the motor 122 and/or adjustable support pad 10, or atanother location, depending on the particular application.

As discussed above, the operation of the tensioning adjustment motorcould be controlled by circuitry or other controls located on or in thesupport pad itself or co-located with the battery and/or motor, and/orcould be controlled remotely by a surgeon or other user, or by a remotecomputer, or by combinations thereof, etc. In the case of the controlsystem being remotely located, the remote control signals could bewirelessly transmitted, such as via radio signals, or could betransmitted through small transmittal lines, such as wires and/orfiber-optic lines, that extend from the adjustment motor to a locationoutside of, or just inside of, the patient's body. For example, in theembodiment depicted in FIG. 11B, the motor 122 could be controlled,and/or the controller (if present) could be reprogrammed, and/or thebattery 128 could be recharged (where run by batteries), remotely usingtechnology similar to that used to control and/or rechargepacemaker/defibrillator controls and batteries. For example, in theembodiment of FIGS. 11B and 11C, the batteries could be recharged usingmagnetic induction by placing a charging element next to the patient'sskin 118 in the area adjacent the battery 128.

FIGS. 12A and 12B depict further embodiments of the invention, with anadjustable support pad 10 having a base portion 134 and a snap-onportion 136. In the embodiment of FIG. 12A, the snap-on portion 136 isinitially free and unattached from the base portion 134. In theembodiment of FIG. 12B, the snap-on portion 136 is movably secured tothe base portion 134 via a hinge 138. The snap-on portion 136 includesone or more snap engaging structures 137 which align with and engageinto corresponding recesses 135 in the base portion 134 when the snap-onportion 136 is snapped onto the base portion 134. In the particularembodiment depicted on FIGS. 12A and 12B, there are multiple holes 140passing through the base portion 134. Depending on the particularapplication, one or more of the holes 140 can serve as suture holesthrough which ordinary suture can be used to fasten the support pad 10to the organ wall, and/or one or more of the holes 140 can serve as padholes through which a tensioning line (such as the suture line 12 ofFIG. 1) is passed. With the base portion 134 secured to the organ andthe tensioning line passed through the pad hole 24, the user adjusts thetension in the tensioning line to the desired level and then secures thetensioning line to prevent further movement to preserve the desiredtension.

The tensioning line can be secured in various ways, depending on theparticular application and support pad. For example, the tensioning linecould be tied off at the desired tension, and/or one or more portions ofthe tensioning line could be passed between the base portion 134 and thesnap-on portion 136 such that the tensioning line is held firmly inplace between the base portion 134 and snap-on portion 136 once thesnap-on portion 136 is snapped onto the base portion 134. One or moreportions of the tensioning line could be wrapped around part of the baseportion 134 and/or snap-on portion 136 to increase the strength of thelocking action on the tensioning line created by snapping the snap-onportion 136 onto the base portion 134. Where the locking of thetensioning line is accomplished by snapping the snap-on portion 136 ontothe base portion 134, the surgeon or other user can adjust the tensionin the tensioning line to a desired level, and then snap the snap-onportion 136 onto the base portion 134, thereby creating a lock thatprevents the tensioning line from further movement and preserves thedesired tension. The surgeon or other user can re-adjust the tension byre-opening the support pad 10 (by snapping the snap-on portion 136 offof the base portion 134), readjusting the tension in the tensioningline, and then snapping the snap-on portion back onto the base portion134 to re-establish the locking action that prevents further movement ofthe tensioning line.

The support pads 10 of FIGS. 12A and 12B include locking lower sutureholes 142 and locking upper suture holes 144 in the base portion 134 andsnap-on portion 136, respectively. The upper and lower locking sutureholes 142, 144 align when the snap-on portion 136 is properly secured tothe base portion 134, and a user can pass ordinary suture through thealigned upper and lower suture holes 142, 144 and tie off the suture tolock the snap-on portion 136 onto the base portion 134 in its closedconfiguration.

Note that a lid-like structure such as the snap-on portion 136 of FIGS.12 a and 12 b could be used in combination with the locking mechanismsset forth in other embodiments of the invention, with the lid-likestructure acting to protect and/or support the locking mechanism and/orother elements of the support pad. For example, a lid-like mechanismcould be combined with the support pad 10 depicted in FIG. 4A, with thelid-like mechanism acting to hold the rotatable upper portion 62 inplace and prevent further rotation when the lid-like structure issnapped-on and/or otherwise secured onto the base portion 60 of thesupport pad 10 of FIG. 4A.

While the invention has been described with reference to particularembodiments, it will be understood that various changes and additionalvariations may be made and equivalents may be substituted for elementsthereof without departing from the scope of the invention or theinventive concept thereof. For example, while the invention isspecifically discussed in application with repair and/or replacement ofchordae tendineae, it has applicability in other areas where it isdesired to repair similar structures. In addition, many modificationsmay be made to adapt a particular situation or material to the teachingsof the invention without departing from the essential scope thereof.Therefore, it is intended that the invention not be limited to theparticular embodiments disclosed herein, but that the invention willinclude all embodiments falling within the scope of the appended claims.

1. A replacement chordae tendinae assembly, comprising: a tensioningline having a first end portion and a second end portion, wherein thefirst end is configured for attachment to a valve leaflet; and anadjustable support pad configured for attachment to a heart wall, theadjustable support pad comprising a first surface configured to beplaced against and secured to the heart wall, the adjustable support padconfigured to receive the tensioning line therethrough and including alocking mechanism configured to slidingly receive the tensioning line ina first direction with respect to the adjustable support pad, and toprevent the tensioning line from sliding in a second direction withrespect to the adjustable support pad, wherein the first direction isopposite to the second direction.
 2. The assembly of claim 1, whereinthe adjustable support pad is configured for attachment to an externalsurface of the heart wall.
 3. The assembly of claim 1, wherein theadjustable support pad comprises a plurality of suture openingstherethrough, wherein the plurality of suture openings are positioned ator adjacent a perimeter of the adjustable support pad.
 4. The assemblyof claim 1, wherein the locking mechanism has an unlocked configurationwherein the tensioning line can slidingly move in the first direction,and a locked configuration wherein the tensioning line is prevented frommoving in the second direction.
 5. The assembly of claim 4, wherein thelocking mechanism in the unlocked configuration allows movement of thetensioning line in the second direction.
 6. The assembly of claim 4,wherein the locking mechanism in the locked configuration preventsmovement of the tensioning line in the first direction.
 7. The assemblyof claim 1, wherein the tensioning line comprises a shock absorbingcomponent.
 8. The assembly of claim 7, wherein the shock absorbingcomponent comprises a spring configured to mimic the characteristics ofone or more papillary muscles.
 9. The assembly of claim 1, wherein theadjustable support pad comprises a pre-formed pad hole configured toreceive the tensioning line therethrough.
 10. The assembly of claim 1,wherein the adjustable support pad comprises a generally compressibleand solid material configured to receive a suturing needle and suturingline therethrough.
 11. A method of replacing a chordae tendon in aheart, comprising: securing a first portion of a replacement chordaetendon to a heart valve leaflet; securing an adjustable support pad toan exterior surface of a heart wall of the heart; passing thereplacement chordae tendon through the heart wall; adjusting tension inthe replacement chordae tendon from outside the heart wall by proximallyor distally moving a second portion of the replacement chordae tendon;and securing the second portion of the replacement chordae tendon to thesupport pad.
 12. The method of claim 11, further comprising: monitoringthe performance of the heart while concurrently adjusting tension in thereplacement chordae tendon.
 13. The method of claim 12, whereinmonitoring the performance of the heart comprises monitoring theperformance of the heart using an imaging system.
 14. The method ofclaim 11, wherein securing the support pad to the exterior surface ofthe heart wall of the heart comprises securing the support pad adjacentthe apex of the heart.
 15. The method of claim 11, wherein securing thefirst portion of the replacement chordae tendon to the heart valveleaflet occurs prior to securing the second portion of the replacementchordae tendon to the support pad.
 16. The method of claim 11, whereinadjusting tension in the replacement chordae tendon from outside theheart wall comprises adjusting tension while the heart is beating. 17.An apparatus for replacing a chordae tendon, the apparatus comprising: atensioning line; an adjustable support pad comprising a first surfaceconfigured to be secured to a heart wall, the adjustable support padfurther comprising an adjustable tensioning element configured to movewith respect to the adjustable support pad, the adjustable support padconfigured to receive and movably hold a portion of the tensioning linevia movement of the adjustable tensioning element; and a controller forcontrolling movement of the adjustable tensioning element.
 18. Theapparatus of claim 17, wherein the controller comprises a motor.
 19. Theapparatus of claim 18, wherein the motor is positioned on or in theadjustable support pad.
 20. The apparatus of claim 17, wherein theadjustable tensioning element is configured for rotational movement.